EMT Training Program Lab Manual. Spring 2010 FT-183L

Transcription

1 EMT Training Program Lab Manual Spring 2010 FT-183L

2 Table of Contents Lab Schedule... 1 Patient Assessment Algorithm... 7 Basic Skills Evaluation Summary Check-Off... 8 Proctor Statements for Midterm Skills... 9 Proctor Statements for Final Skills Lab 1 Skills Removal of Contaminated Gloves Body Substance Isolation Initial Assessment Chest Auscultation Vital Signs Head-Tilt/Chin-Lift Maneuver Jaw Thrust Maneuver Lab 2 Skills Pocket Mask Ventilation Bag Valve Mask Ventilation Bag Valve Mask Ventilation, Two-Person Oropharyngeal Airway Nasopharyngeal Airway Suctioning the Oropharynx Lab 3 Skills Oxygen Administration Sellick s Maneuver Detailed Physical Exam Application of a Cervical Collar Patient Interview/Assessment and General Event Flow Lab 4 Skills Neurological Exam Bleeding Control and Shock Management Joint Immobilization Long Bone Immobilization Bandaging and Splinting an Open Extremity Fracture Sling and Swathe Immobilization Lab 5 Skills Kendrick Extrication Device (KED) Helmet Removal Lifting and Moving Patients Spine Immobilization Supine Patient Spine Immobilization Standing Patient Application of Soft Restraints i

3 Table of Contents Lab 6 - Scenario Stations Lab 7 - Midterm Skills Review Lab 8 Skills Administration of Glucose Administration of Nitroglycerin Epinephrine Auto-Injector Administration of Nebulized Medication Administration of Activated Charcoal Metered Dose Inhaler Medical Patient Assessment-Responsive: Chest Pain Medical Patient Assessment Lab 9 Skills Adult and Child One-Rescuer CPR One-Rescuer CPR with AED Infant One- and Two-Rescuer CPR Adult and Child Foreign Body Airway Obstruction: Unresponsive Patient Adult and Child Foreign Body Airway Obstruction: Responsive Patient Infant Foreign Body Airway Obstruction Endotracheal Tube BVM Ventilation Artificial Ventilation of a Stoma Breather Suctioning Through an Endotracheal Tube Lab 10 Skills Sucking Chest Wound Emergency Childbirth Hare Traction Splint Sager Traction Splint Impaled Objects Penetrating Eye Injury Impaled Object Stabilization Avulsion (Complete) or Amputation Lab 11 - MCI Drill Lab 12 Skills Trauma Patient Assessment Rapid Extrication Additional Skills Pulse Oximetry Insertion of Esophageal Combitube (ETC Airway) Insertion of Nasogastric Tube (NG Tube) Cooling Measures - Infant Vital Signs Check-Off CPR Check-Off Mnemonics ii

4 Lab Schedule Spring 2010 A minimum of one hour per week outside of class is required of all students to view the EMT skills videos online, and to study the lab manual skills sheets. Students will find the skills videos online at Lab 1 2/19 Watch the following videos prior to lab: Introduction to patient assessment, initial assessment and scene size-up, BSI, head tilt, jaw thrust, vital signs (videos 1, 2, 5, 6) Add slips given as needed, SRTs formed Introductions of SRT members, last day for lab fee payment ($35 checks to Cabrillo EMT), glove sizing and distribution Review Lab Policies from lab orientation Practice Proper Removal of Contaminated Gloves skill sheet (no video) Body Substance Isolation (BSI) skill sheet and video Weekly equipment check-off procedure Go over patient documentation: Patient Care Worksheet; Refusal of Service (AMA) Head-Tilt Chin-Lift Maneuver skill sheet and video Jaw Thrust Maneuver skill sheet and video Initial Assessment skill sheet and video Chest Auscultation skill sheet Vital Signs (skill sheet and videos 1, 2, 5, & 6) o Pulse, Respirations, Skin signs, Pupil Assessment Lab 2 2/26 Watch the following videos prior to lab: Vital Signs BP (3, 4), pocket mask, 2- Person BVM, OPA, NPA, Oral suctioning, Adult Rescue Breathing with Bag Mask (see BLS for the HCP video) Equipment check-off Pocket mask distribution Pt. Assessment Algorithm (lab manual) Vital Signs (skill sheet and videos 3, & 4) o BP Auscultated and Palpated and review previous VS Airway management skills (skill sheets and videos) o Pocket Mask Ventilation o Bag Valve Mask Ventilation o Bag Valve Mask Ventilation, Two Person o Oropharyngeal Airway o Nasopharyngeal Airway o Suctioning the Oropharynx Practice Initial Assessment Quiz #1: Initial Assessment skill sheet individually quizzed in SRTs 1

5 Lab Schedule Spring 2010 Lab 3 3/05 Watch the following videos prior to lab: oxygen tank assembly, nasal cannula, non-rebreather mask, Sellick s Maneuver, pulse oxymetry, trauma patient assessment, significant MOI, no significant MOI, detailed physical exam, ongoing assessment, cervical collars Equipment check-off Oxygen Administration skill sheet o O2 Tank Assembly o Nasal Cannula o Non-rebreather Mask Sellick s Maneuver skill sheet Detailed Physical Exam (DCAP-BTLS) Application of a Cervical Collar skill sheet Scenario: Introduction to patient interview assessment (on website) SAMPLE History Questions Vital signs check off Optional HM-FRA certification - Sat 3/6 (FT 190 HM with G. Niblock) Lab 4 3/12 Watch the following videos prior to lab: bleeding and shock, dressing and bandaging, long bone splinting, joint splinting, sling and swathe Equipment check-off Neurological Exam skill sheet Bleeding Control and Shock Management skill sheet Joint Immobilization skill sheet Long Bone Immobilization skill sheet Bandaging and Splinting an Open Extremity Fracture skill sheet Sling and Swath skill sheet Vital signs check off Quiz #2: Initial Assessment skill sheet individually quizzed in SRTs Optional WMD-FRA certification - Sat 3/13 (FT 190 NBC with G. Niblock) 2

6 Lab Schedule Spring 2010 Lab 5 3/19 Watch the following videos prior to lab: KED, immobilizing supine pt, immobilizing standing pt, helmet removal, rapid extrication, lifting and moving pts, soft restraints Equipment check-off Kendrick Extrication Device (KED) skill sheet Helmet Removal skill sheet Lifting and Moving Patients skill sheet Backboard Use and strapping techniques Spine Immobilization Supine Patient skill sheet Application of Soft Restraints skill sheet Spine immobilization Standing Patient skill sheet Use of gurney, scoop, stair chair, readibed, sit pick, rescue seat demos Vital signs check off ***Initial Assessment Skill Test 3/23 and 3/25 with K. Hurst by appointment. Includes student/teacher conference, written midterm exam review and field ride-along agency assignment. Lab 6 3/26 Scenario Stations Major Trauma (unconscious) Life Guard Beach Drowning Tib/Fib fracture with precautionary c-spine (minor trauma) Vital signs check off NO LAB 4/2 NO LAB (Spring Break) Lab 7 4/9 Midterm Skills Review Mid-term Skills Practice o 1 Person BVM (Oropharyngeal Airway and Bag Valve Mask Ventilation) o Oxygen Administration o NPA and Suctioning (Nasopharyngeal Airway and Suctioning the Oropharynx) o Vital Signs o Kendrick Extrication Device (KED) o Patient Assessment Detailed Physical Exam Vital signs check off 3

7 Lab Schedule Spring 2010 Saturday 4/10 - MIDTERM Skills Test 1000A 1430P Mid-term Skills Tests o 1 Person BVM (Oropharyngeal Airway and Bag Valve Mask Ventilation) o Oxygen Administration o NPA and Suctioning (Nasopharyngeal Airway and Suctioning the Oropharynx) o Vital Signs o Kendrick Extrication Device (KED) o Patient Assessment Detailed Physical Exam Lab 8 4/16 Watch the following videos prior to lab: activated charcoal, glucose paste, metered dose inhaler, nitroglycerin, epi auto inject, nebulized medication, responsive medical pt, unresponsive medical pt Medical Patient Assessment - Responsive: Chest Pain skill sheet Administration of Glucose skill sheet Administration of Nitroglycerin skill sheet Epinephrine Auto-Injector skill sheet Administration of Nebulized Medication skill sheet Administration of Activated Charcoal skill sheet Metered Dose Inhaler skill sheet Medical Patient Assessment skill sheet (discuss the differences in assessment between the responsive and unresponsive medical patient) Medical Scenarios Vital signs check off Lab 9 4/23 Watch the following videos prior to lab: adult 1-rescuer CPR, adult compressions, adult breaths with mask, adult compressions and breaths, adult assessment, adult rescue breathing with bag mask, adult 2-rescuer CPR demo, adult 2-rescuer CPR and AED, adult 2-rescuer advanced airway, child CPR sequence, infant 1-rescuer CPR, infant compressions, infant 2-rescuer CPR demo, ET intubation, Suctioning through an ET tube, Combitube Adult and Child One-Rescuer CPR skill sheet One-Rescuer CPR with AED skill sheet Infant One- and Two-Rescuer CPR skill sheet Adult and Child FBAO: Unresponsive Patient skill sheet Adult and Child FBAO: Responsive Patient skill sheet Infant FBAO skill sheet Endotracheal Tube BVM Ventilation (Advanced Airway) skill sheet Artificial Ventilation of a Stoma Breather skill sheet Suctioning Through an Endotracheal Tube Vital signs check off CPR check off 4

8 Lab Schedule Spring 2010 Lab 10 4/30 Watch the following videos prior to lab: hare traction splint, sager traction splint, assisting with childbirth Equipment check-off Emergency Childbirth skill sheet Hare Traction Splint skill sheet Sager Traction Splint skill sheet Avulsion (Complete) or Amputation skill sheet Impaled Objects - Penetrating Eye Injury skill sheet Impaled Object Stabilization skill sheet Sucking Chest Wound skill sheet Vital signs check off CPR check off Lab 11 5/7 MCI Drill Equipment check-off MCI and Triage Drill Lab 12 5/14 Trauma patient and rapid extrication scenarios Watch the following videos prior to lab: rapid extrication, immobilize supine pt, immobilize standing pt, trauma patient significant mechanism of injury Equipment check-off Trauma Patient Assessment skill sheet (Significant MOI) Trauma Patient Assessment skill sheet (No Significant MOI) Spine immobilization Standing Patient skill sheet (review) Rapid Extrication skill sheet and scenarios Trauma Patient Scenarios Vital sign check off CPR check off 5

9 Lab Schedule Spring 2010 Lab 13 5/21 Final Skills Review Equipment check-off Final Skills Practice - Open Lab o Patient Assessment Medical (Medical Patient Assessment Responsive: Chest Pain) o One-Rescuer CPR with AED o Emergency Childbirth o Infant CPR 1and 2 Person o Hare Traction o Bleeding Control and Shock Management o Sling and Swathe Vital sign check off CPR check off Saturday 5/22 Final Skills Test 1000A 1430P Final Skills Tests o Patient Assessment Medical (Medical Patient Assessment Responsive: Chest Pain) o One-Rescuer CPR with AED o Emergency Childbirth o Infant CPR 1and 2 Person o Hare Traction o Bleeding Control and Shock Management o Sling and Swathe 6

10 Patient Assessment Algorithm 7

11 8

12 Proctor Statements for Midterm Skills Initial Assessment: An initial assessment is an EMT s bread and butter. From memory verbalize down the initial assessment exactly as it is written on the skills sheet. Demonstrate how to open an airway with a head-tilt, chin lift method and with a jaw thrust method if you suspect spinal injuries. Patient Assessment Detailed Physical Exam: A detailed physical assessment begins with scene size-up and initial assessment. Assume you have already completed these two steps. The assessment you complete for a minor versus major trauma is different. What is the difference? Student states, I would do a focused history and physical exam on a minor trauma patient and a rapid trauma assessment on a major trauma patient. Explain the pre-assessment steps in the detailed physical exam. Student verbalizes down the 3 bullet points under pre-assessment. State what the acronym DCAP-BTLS stands for. Student states, Deformity, contusions, abrasions, punctures (or penetrations), burns, tenderness, lacerations and swelling. Continue to perform all assessment steps you would do to look for unknown injuries on a trauma patient. Student works down the head to toe and verbalizes all bullet points on the skill sheet. One bullet point missed throughout the entire exam is permissible but more than one constitutes a failure for this skill. At the end of the exam ask, Is there anything else you would like to add? 1 Person BVM: You have been asked to ventilate a non-breathing patient. Measure and insert an OPA and then demonstrate ventilating an adult patient with a bag valve mask. Oxygen Administration: In this station you need to assess patient s need for oxygen, assemble the oxygen administration system, and demonstrate how to administer oxygen to a patient with a nasal cannula and a non-rebreather mask. NPA and Suctioning: Demonstrate measuring and inserting an NPA. Assemble and demonstrate how to suction a patient with a rigid suction tip. Vital Signs: Using the proctor demonstrate how to take a respiration rate, pulse rate and auscultated blood pressure. Verbalize how to take a palpated blood pressure. Student does not have to actually demonstrate palpated BP, only explain how to do it. KED: You have a patient who has an isolated spinal injury in the neck and back. He is complaining of midline neck and back tenderness and is feeling numbness in both arms. Demonstrate assessing the patient s need for a KED and then place the KED correctly on the patient. Do not place the patient on the back board but verbalize what you would do to fully immobilize the patient if the backboard were needed. 9

13 Proctor Statements for Final Skills Hare Traction: You arrive on scene of a patient who is complaining of leg pain. The patient states the pain is 9 out of 10. The pain is accompanied by swelling and bruising to the middle section of the femur. There does not appear to be any hip or knee involvement in the injury. You suspect that the patient has an isolated closed mid-shaft femur fracture. Place the hare traction splint on the patient to immobilize the possible fractured femur. Emergency Childbirth: You arrive on scene of a patient who states she thinks she is about to give birth to a baby. After introducing yourself what assessment question should you ask to ascertain whether you should check to see if the baby is coming? (Answer: Do you feel the need to bare down or move your bowels? ) What 4 key questions would you like to ask if time permits? After the questions, proceed with the necessary steps to deliver this woman s baby. (Key point: After the head of the baby delivers be sure that the student checks for the presence or absence of the umbilical cord around the baby s neck). Do not have student actually close the clamps on the cord but only demonstrate the landmarks to place them. One-Rescuer CPR with AED: You are in a gym where a man goes suddenly unconscious while playing basketball. Assume the Emergency Response System has been activated. You are working at the gym and arrive within two minutes with an AED. You also have a pocket mask or BVM available. Demonstrate what you would do to treat this individual. (Student should work through the skill sheet.) When you recheck for a pulse, you find one, but the patient is not breathing. Demonstrate what you need to do now. (Student should demonstrate rescue breathing, 1 breath every 5-6 seconds.) Continue to demonstrate rescue breathing for 1 full minute. (Student will give breaths in the minute time with the majority of them resulting in visible chest rise.) The patient is now breathing on his own. What further treatment could you do? (Student should state, Place the patient in recovery position and put them on a non-rebreather mask at 15 liters per minute.) Bleeding Control and Shock Management: You have a patient who has a deep gash to their forearm that appears to be spurting bright red blood. Demonstrate how to control the bleeding. Student should hold pressure, elevate and demonstrate correct pressure point at the brachial artery. Student should then apply a pressure bandage using a 4X4 and cling or a triangular bandage. Proctor states, If your patient is showing signs of shock what should you do? Student should verbalize down the rest of the skill sheet. If student has not already stated, proctor asks, What 3 things should you reassess during bleeding control and shock management? Student should state, Check for presence of radial pulse, observe skin signs and check for capillary refill time. 10

14 Infant CPR 1 and 2 Person: You are at a party with some friends off duty when a parent runs up to you with his infant and says, My baby is not breathing! Help her! The baby is limp and turning blue. Place the baby on a firm surface. Proceed with your assessment. (Student should work through the Infant One- and Two-Rescuer CPR skills sheet beginning with assessing for responsiveness and activating EMS. Student will demonstrate 5 cycles of 30:2 compressions and ventilations beginning with opening the airway and checking for breathing.) The proctor now states, After the 5 th cycle of compressions and ventilations you recheck for a pulse and still do not find one. I will act as a second rescuer and take over at airway. (Student should demonstrate the 2 thumb-encircling hands technique of chest compressions and change to a 15:2 compression to ventilation ration for 2 person infant CPR.) Do 2 cycles of CPR. The proctor then states, After 2 minutes you assess the infant and there is a pulse, but the baby is not breathing. Demonstrate what you need to do. (Student should demonstrate rescue breathing, one breath every 3-5 seconds with the majority of ventilations resulting in visible chest rise.) Patient Assessment Medical: Proctor states, Your patient complains of cardiac-like chest pain. Assume the scene size-up and initial assessment have been completed. What questions will you ask your patient as part of your chest pain assessment? (Student should answer according to OPQRST.) Proctor asks, What does SAMPLE stand for? (Student answers per skill sheet.) Proctor asks, What do you assess during your focused physical exam? (Student works through the physical exam and focused history questions on the skills sheet.) Proctor asks, What else do you do for a patient with suspected cardiac chest pain? (Student states, Obtain baseline vital signs, assist patient to take their own nitroglycerin if BP is above 100 systolic and they are not on ED medication, make transport decisions and consider doing a complete detailed physical exam. ) Proctor states, This completes the medical assessment. Sling and Swathe: You respond to a patient who has what appears to be a dislocated shoulder. The patient is self splinting the injury. There is no second rescuer. Demonstrate how to immobilize this injury using a sling and swathe. (Student should assess for circulation, sensation and motor function in the injured extremity three times.) 11

15 12

16 13 Body Substance Isolation (BSI) Preparation Explain to patient the reasons for applying BSI. Apply gloves. Apply eye protection. Apply mask, if appropriate. Apply gown, if appropriate. Patient Interaction Provide appropriate assessment and treatment. Consider changing gloves if they are to be worn for an extended period of time. Cleanup Gather any contaminated materials from the scene, and place in an appropriate disposal bag or container. Remove personal protection when there is no further risk of exposure. Be careful not to contaminate yourself during removal of personal protection equipment. Dispose all contaminated materials and gloves, masks and gowns in proper infection control waste disposal container. Wash hands as soon as possible with an approved infection control soap or other solution. Document the incident. Change gloves immediately if they become damaged. If at any time you feel you may have been exposed to blood or body fluids, fill out appropriate forms provided to you by your agency, and contact your infection control coordinator. If you have been directly exposed, seek medical attention immediately. Consult your agency s policies and procedures.

17 14 Initial Assessment Scene Safety and Size-up (5 questions) Is the scene safe? Trauma patient (Mechanism of Injury (MOI)) or medical patient (Nature of Illness (NOI))? What is the number of patients? What additional resources do I need? Do I need to take C-spine precautions? Initial Assessment Overview Verbalize general impression of patient. (big sick or little sick) Determine level of consciousness. Is the patient alert, or responsive to verbal or painful stimuli, or unresponsive? (AVPU) If the patient is alert, are they oriented to person, place, time and event? (A&OX4) Determine chief complaint. Airway Is the airway open? If not open it with the head-tilt/chin-lift method or modified jaw thrust if C-spine precautions are needed. (Demonstrate these two methods of opening the airway.) Use suction as needed. Insert OPA or NPA adjuncts if appropriate. Breathing Assess for the presence, rate, rhythm and quality of breathing. Apply oxygen if needed here. Begin rescue breathing if patient is apneic. Circulation Assess for the presence, rate, regularity and strength of the pulse. If no pulse begin CPR and attach an AED. Assess skin color, temperature and moisture condition. Check for and control any major bleeding. Initiate shock treatment if signs of shock are apparent. Decide Patient priority for immediate transport Objective: The examinee will perform an initial assessment and verbalize through entire skill verbatim. Equipment: Manikin or simulated patient.

18 15 Chest Auscultation Direct patient to breathe deeply through an open mouth. Place stethoscope diaphragm directly on patient s skin. Listen In a minimum of 4 fields anterior (front) and posterior (back): Anterior 3 fingers breadth below the clavicle at the midclavicular line, on right and left sides. Just below the nipple line (6 th intercostals space) midaxillary, on right and left sides. Posterior Upper back, 3 fingers breadth below the shoulder (not over the scapular bone), on right and left sides. 3 fingers breadth below the scapular bone, on right and left sides. Objective: The examinee will demonstrate proficiency in auscultating breath sounds. Equipment: Stethoscope, simulated patient.

19 16 Vital Signs Respirations Check for the presence or absence of breathing by watching for the rise and fall of the chest. Observe the patient s position (tripod position indicates respiratory difficulty). Count the number of breaths in 30 seconds and multiply by 2 or in 15 seconds and multiply by 4 to determine the number of breaths per minute. Report the rate, rhythm, and quality of breathing. Pulse Palpate the radial pulse with two fingers if the patient is conscious. Palpate the carotid pulse if the patient is unconscious. For infants palpate the brachial pulse. Count the number of beats in 15 seconds and multiply by 4. If pulse is slow or irregular count the beats in 30 seconds and multiply by 2. Report the rate, regularity and strength of the pulse. Blood Pressure Auscultated Apply blood pressure cuff 1 above the antecubital area. Palpate the brachial artery and place the center of the bladder just above it. Don t place it over clothing. Fit it snuggly. Place the diaphragm of the stethoscope over the brachial artery. Inflate the blood pressure cuff rapidly. Deflate the cuff slowly and note when the heart beat is first heard and when it is no longer heard. These two numbers are the systolic and diastolic numbers of the blood pressure. Report the auscultated systolic and diastolic blood pressure. Cuff should cover 2/3 of upper arm. Procedure continues on the next page.

20 17 Vital Signs Procedure continued from previous page Blood Pressure Palpated With blood pressure cuff still in place, feel for the radial pulse. Inflate the cuff to at least 10mm Hg over the point where the radial pulse ceases to be palpable. Deflate cuff slowly. Note when the radial pulse returns. This is the systolic blood pressure. Report the systolic blood pressure over P for palpated. Skin Check for overall color of the skin, mucous membranes and nailbeds. Determine skin temperature by feeling the forehead with the back of the hand. Determine skin moisture. Pupils Note the size of the pupil before shining any light into the eyes. Cover one eye while shining light into the other eye. Move the light from lateral (outside the eye) to medial. Note the reactivity and change in size of the pupil. Repeat the exam on the other eye. Document PERL (pupils are equal, round, regular and reactive to light) or pertinent negatives if pupils do not respond normally. Objective: The examinee will demonstrate how to take vital signs on a patient. Equipment: Blood pressure cuff (sphygmomanometer), stethoscope, penlight, patient.

21 18 Head-Tilt/Chin-Lift Maneuver Positioning Place the patient in the supine position. Place yourself to the side of the patient if possible. Maneuver Place the palm of one hand on the patient s forehead. Place the fingers of your other hand under the bony part of the lower jaw near the chin. While applying pressure down on the forehead, simultaneously using the fingers of the other hand lift the jaw upward, bringing the chin forward. Do this until the teeth of the lower mouth almost touch the teeth of the upper. Try not to close the patient s mouth during maneuver. Assess for breathing and ventilate as needed. Objective: The examinee will demonstrate the proper method for the head-tilt/chin-lift maneuver. Equipment: Manikin.

22 19 Jaw Thrust Maneuver Positioning If the patient is not Place the patient in the supine position. supine, carefully keep the Place yourself at the top of the patient s head if possible. patient in a neutrally aligned position and roll them as a unit into the supine position. Maneuver Without moving the head and neck, carefully place one hand on either side of the patient s head near the orbits. Try not to close the Place your thumbs just inferior to the eyes and lateral to the nose. patient s mouth during Place your fingers at the angle of the jaw below the ears. maneuver. Without moving the head and neck, using your index and middle fingers, pull the angle of the jaw forward (jut the jaw). Assess for breathing and ventilate as needed. Objective: The examinee will demonstrate the proper method for the jaw thrust maneuver. Equipment: Manikin.

23 20 Pocket Mask Ventilation Assess Assess patient s breathing. Look, listen and feel (with your ear over the patient s mouth watch for chest rise for 5-10 seconds). Assemble Push out dome of face piece. Attach one-way valve to mask, exhalation valve away from nose end of mask. Position mask over patient s nose & mouth. Position yourself at head of patient. Airway Open the airway by using the head tilt/chin lift or modified jaw thrust if C-spine precautions are needed. Insert an OPA or NPA as appropriate. Connect oxygen tubing to pocket mask if there is an oxygen inlet. Some types of pocket masks do not have an O 2 inlet. Center the pocket mask on the patient s face so that the triangle is over the bridge of the patient s nose and the wider part is placed between the lower lip and the chin. Breathing Seal mask by circling thumb & 1 st finger around top of mask and opening airway by 3 rd, 4 th & 5 th fingers lifting the jaw. Pull the jaw up towards the mask. Blow slowly into valve over 1-2 seconds. Observe for chest rise. Remove mouth and allow patient to exhale. Circulation If the patient does not have a pulse, perform CPR as usual. If alone consider using the attached head strap if there is one. This will help to maintain alignment of the mask on the patient. Reassess Airway/Ventilations Objective: The examinee will demonstrate proficiency ventilating an apneic patient using a pocket mask. Equipment: Adult airway manikin, pocket mask. Special Instructions: To clean remove filter. Wash and scrub with soapy water. Rinse in clean water. Submerge for 10 minutes in 1:64 household bleach/water solution. Rinse. Air dry. Ventilations should be 1 breath every 5 seconds for an adult. Children and infants should be ventilated at a rate of 1 breath every 3-5 seconds depending on their size.

24 21 Bag Valve Mask Ventilation Assess Assess patient s breathing. Look, listen and feel (with your ear over the patient s mouth watch for chest rise for 5-10 seconds). Assemble Equipment Open oxygen source and ensure pressure is adequate. Connect one end of oxygen tubing to flow meter of O 2 cylinder and the other to the BVM. Set flow meter to 15 LPM. Attach mask to BVM. Airway Open airway by tilting patient s head back in the sniffing position. Suction airway, if required. Measure and insert an OPA. Ventilation Position yourself at head of patient. Position the mask on the patient and using the E-C technique, seal the mask and maintain an open airway. With your other hand, squeeze the bag slowly (1 second) while watching for chest rise. Give one breath every five to six seconds (10 to 12 breaths per minute) for adults. Give one breath every three to five seconds (12 to 20 breaths per minute) for children and infants. Watch for chest rise on each ventilation. Reassess Airway /Ventilations Ensure the equipment is operational. Do not ventilate a patient with fluid in their pharynx. If the patient has a mustache or beard, there are no differences in this procedure. Objective: The examinee will demonstrate proficiency ventilating an apneic patient using a Bag Valve Mask attached to a supplemental O 2 source. Equipment: Adult airway manikin, BVM, OPA, O 2 tank with regulator/flow meter, oxygen tubing.

25 22 Bag Valve Mask Ventilation, Two-Person Assess Assess patient s breathing. Look, listen and feel (with your ear over the patient s mouth watch for chest rise for 5-10 seconds). Assemble Equipment Open oxygen source and ensure pressure is adequate. Ensure the equipment is Connect one end of oxygen tubing to flow meter of O 2 cylinder and the other to the BVM. operational. Set flow meter to 15 LPM. Attach mask to BVM. Airway Do not ventilate a patient Open airway by tilting patient s head back in the sniffing position. with fluid in their Suction airway, if required. pharynx. Measure and insert an OPA. Ventilation First EMT: Position yourself at head of patient. Position the mask on the patient and using the E-C technique with each hand, seal the mask and maintain an open airway. If the patient has a Second EMT: mustache or beard, there Squeeze the bag slowly (1 second). are no differences in this Give one breath every five to six seconds (10 to 12 breaths per minute) for adults. procedure. Give one breath every three to five seconds (12 to 20 breaths per minute) for children and infants. Both EMTs: Watch for chest rise on each ventilation. Reassess Airway /Ventilations Objective: The examinee will demonstrate proficiency ventilating an apneic patient using a Bag Valve Mask attached to a supplemental O 2 source, along with a second rescuer. Equipment: Adult airway manikin, BVM, OPA, O 2 tank with regulator/flow meter, oxygen tubing, second rescuer.

26 23 Oropharyngeal Airway Position Patient Place the patient in supine position. Measure Airway Size airway from earlobe to corner of patient s mouth or angle of jaw to midline of the lip. Select proper size of oral airway. Insert Open patient s mouth using the cross-finger technique. Insert the airway with tip pointing toward roof of mouth until it reaches the base of the tongue. Gently rotate airway 180 degrees. Flange should rest against the outside of the lips. Reassess Airway/Ventilations If the patient begins to gag at any stage of this procedure immediately remove the airway. Remember to gently insert the airway. Objective: The examinee will demonstrate proficiency in sizing and placing an oropharyngeal airway. Equipment: Adult airway manikin, a variety of OPA sizes. Indications: Unconscious patient with no gag reflex.

27 24 Nasopharyngeal Airway Measure Airway Visually select airway diameter slightly smaller than the patient s nostril or compare NPA external diameter with the diameter of patient s smallest finger. Size airway by measuring from patient s side of nostril to the earlobe. Lubricate with water soluble lubricant. Insert Gently push the tip of the nose upward. Insert NPA with bevel pointing toward septum, gently rotating the airway side to side while advancing it. At no time should the airway be forced into the nostril. If patient begins to gag immediately remove the airway and prepare to suction as needed. Flange or proximal ring should rest against the end of the nostril when NPA is placed properly. Reassess Airway/Ventilations Objective: The examinee will demonstrate how to size and place a nasopharyngeal airway. Equipment: Adult airway manikin, a variety of nasopharyngeal airways, lubricant. Indications: Semiconscious or unconscious patient with a gag reflex unable to tolerate an OPA.

28 25 Suctioning the Oropharynx Assess Open airway by tilting patient s head back in the sniffing position. Assess if patient s airway is in need of suctioning. Assemble Assemble suction equipment by connecting rigid tip to tubing, then to suction source. Ensure suction unit is working by turning it on, then off. Airway Measure depth of rigid suction tip insertion by measuring the distance from tip of earlobe to side of nose following the curvature of the jaw. Turn suction unit on. Place patient on his or her side, or turn head to the side if possible. Grasp lower jaw of patient and open the mouth wide. Insert suction catheter to the measured depth. Suction as catheter is withdrawn by placing your finger over the hole in the catheter tip. Limit suctioning to 15 seconds. Irrigate suction tip with solution as needed. Repeat the above technique as needed. Breathing Ventilate apneic patient after suctioning or administer O 2 as needed to a breathing patient. Reassess Airway/Ventilations Same measurement length as an NPA. Use pediatric setting for children and infants. Limit child and infant suctioning to 5 seconds using flexible suction tube only. Objective: The examinee will demonstrate proficiency in suctioning the oropharynx using a rigid suction tip. Equipment: Adult airway manikin, rigid suction tip, connective tubing, suction unit, irrigating solution and container.

29 26 Oxygen Administration Assess Assess patient s need for oxygen by observing patient s skin signs, pulse oximetry level and breathing effort. Assemble Connect yoke of the flowmeter-regulator to O 2 tank by aligning pins into appropriate spaces on the tank valve. Check for O-ring gasket. Hand-tighten the T screw on the oxygen regulator. Slowly open tank valve (use key if required) one-half turn to charge the regulator. Check pressure gauge in O 2 tank to see that adequate O 2 is present. Verbalize pressure in PSI. Nasal Cannula Select nasal cannula and connect tubing to nipple of oxygen regulator. Instruct the patient to Set flow rate at 1-6 LPM. breathe normally while Place nasal cannula in manikin s nose with nasal prongs curving downward. the cannula is in place. Secure cannula by positioning tubing over the manikin s ears. Bring remainder of tubing under the manikin s chin. Slide slip loop in place. Non-rebreather Mask Select non-rebreather mask and connect tubing to nipple of oxygen regulator. Instruct the patient to Set flow rate at LPM. breathe normally while Fill mask reservoir by placing finger over port at top of bag. the mask is in place. Place mask over manikin s nose and mouth with apex of mask over the bridge of nose. Secure mask on manikin by positioning the elastic strap so that it rests above the manikin s ear and tighten strap as needed. Reassess Airway/Ventilations Objective: The examinee will demonstrate how to connect a flowmeter-regulator to an O 2 cylinder, turn it on and administer O 2 via a nasal cannula and non-rebreather mask. Equipment: Adult airway manikin, O 2 tank, flowmeter-regulator, cylinder key, nasal cannula, non-rebreather mask.

30 27 Sellick s Maneuver Sellick s Maneuver is a quick, effective way of preventing gastric distension and/or regurgitation in a patient who cannot protect his/her own airway. It also helps during manual ventilation and endotracheal tube intubation. Position Patient Ensure that the patient is in the supine position. Place patient s head in neutral position. Locate Cricoid Cartilage Palpate the depression inferior to the thyroid cartilage (Adam s apple). The projection just inferior to this depression is the cricoid cartilage. Place the thumb and index finger of one hand on the anterior and lateral aspects of the cricoid cartilage, just next to the midline. Apply Pressure Apply firm, but gentle posterior pressure. More pressure is needed to prevent regurgitation than gastric distention. Too much pressure must be avoided because it will occlude the airway. Objective: The examinee will be able to explain why to use Sellick s Maneuver as well as demonstrate the correct application of Sellick s Maneuver. Equipment: Manikin.

31 28 Detailed Physical Exam Perform scene size-up and initial assessment. Student verbalizes, I would do a focused history and physical exam on a minor trauma patient and a rapid trauma assessment on a major trauma patient. Pre-assessment Expose patient or injuries for assessment. Direct crew to prepare backboard for patient transport (if needed). Obtain SAMPLE history and vital signs as appropriate Detailed Physical Examination (DCAP-BTLS)-Student states I will be using the acronym DCAP-BTLS during my exam and it stands for: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations and Swelling. Assess the Head Inspect and palpate the scalp and cranium for DCAP-BTLS plus crepitation and bleeding. Inspect the eyes for pupil size and reactivity, bleeding in the anterior eye chamber and signs of raccoon eyes. Inspect the ears and nose for bleeding or clear fluid drainage (CSF). Inspect the back of the ears for bruising (Battle s sign). Inspect the mouth for loose or broken teeth, lacerations on the tongue, unusual odors and listen for a noisy airway (snoring, strider and secretions sounds). Assess the neck Inspect for DCAP-BTLS and palpate neck and cervical spine. Check for jugular vein distension (JVD), tracheal deviation and medic alert tag. Inspect for stoma. Student verbalizes, I would apply a cervical collar at this point of the physical exam if appropriate. Procedure continues on next page.

32 29 Detailed Physical Exam Procedure continued from previous page Assess the Chest Palpate the clavicles. Inspect the chest for DCAP-BTLS plus crepitation, scars, and paradoxical motion. Palpate the chest (barrel hoop and sternum press with edge of hand). Auscultate for presence and equality of breath sounds. Assess the Abdomen Inspect the abdomen for DCAP-BTLS. Palpate the 4 quadrants of the abdomen for distension, rigidity, guarding and pulsating masses. Assess the Pelvis Inspect the pelvis for DCAP-BTLS plus priapism, incontinence and bleeding. Palpate the pelvis by gently pressing on the front and sides (barrel hoop) checking for stability. Check for outward rotation and shortening of each leg (sign of possible hip fracture). Assess the lower extremities Inspect for DCAP-BTLS and palpate the lower extremities. Assess for pulse, motor function and sensation (PMS) of the lower extremities. Assess the upper extremities Inspect for DCAP-BTLS and palpate the upper extremities. Check for medic alert tag. Assess for pulse, motor function and sensation (PMS) of the upper extremities. Assess the back and buttocks Roll patient onto side. Inspect and palpate the posterior torso and buttocks for DCAP-BTLS. Treat any injuries discovered on the detailed physical exam as appropriate. Do not rock the pelvis hard. Often done when log rolling the patient to a spine board. Objective: The examinee will demonstrate proficiency in performing a detailed physical exam. Equipment: Patient or manikin, penlight, stethoscope, mat, shears for exposing injuries.

33 30 Application of a Cervical Collar Approach Approach the patient from the front, instructing them not to move. Explain the procedure to the patient and gain consent to treat. Stabilization Maintain manual cervical stabilization. Have a second rescuer do this if possible. Assessment Inspect and palpate the neck and cervical spine. Check for jugular vein distension (JVD), tracheal deviation and medic alert tag. Inspect for stoma. Evaluate pulse, motor function and sensation (PMS) in all extremities. Measure the collar for a proper fit according to manufacturer s instructions. Application Angle the collar for proper placement. If patient is supine, slide the collar between the neck and the ground first, and then wrap it around the front. If patient is sitting or standing, slide the chin portion of the collar up the chest to the chin, then wrap the collar around the back of the neck. Fasten the collar in place. Check for proper fit. Reassess Reassess pulse, motor function and sensation (PMS) in all extremities. Objective: The examinee will demonstrate the proper application of a cervical collar. Equipment: Assorted sizes of cervical collar, patient, second rescuer. The collar should not hyperextend the neck or fit so snugly that it constricts the airway. Maintain manual stabilization until patient is fully immobilized.

34 Patient Interview/Assessment and General Event Flow On scene/scene survey BSI precautions (PPE) Scene safety Additional resources Number of patients Type of patient(s), medical or trauma. If trauma determine need for cervical spine precautions Pre-contact impressions What is the nature of the event (trauma, (example-vehicle accident) or medical (example-seizure) or both (example-vehicle accident with seizure) Visual impressions of the patient o Conscious/unconscious o ABC s o Skin signs o Big sick/little sick Initial Patient Contact Conscious patient o If trauma is suspected take initial c-spine precautions while making introduction o Introduce yourself and let the patient know: Who you are (your name, Hi, my name is. ) Your position ( I m an EMT, or I m an emergency medical technician, or a phrase that will denote your competence, credibility and authority.) Why you are with the patient ( I m here to help, and/or, you called us today, etc.) o Obtain chief complaint ( Why did you call us today? How can we help you today? What happened? Etc.) o Update General Impression ( Big sick/little sick. ) o Conscious patient intro example: Hi, my name is, I m an EMT-medic and I m here to help you. Can you tell me why you called us? OK. I m going to ask you a few basic questions so that we can continue to help you. o Level of Consciousness (LOC) Person, place, time and purpose or event o Start SAMPLE and physical exam o Prepare for transport (NOTE: Criteria for immediate transport ( load and go ) are unconscious patient, uncontrolled bleeding, complications of childbirth and severe spinal injuries.) o Treat patient as indicated during interview/assessment process 31

35 Initial Patient Contact Unconscious patient o ABC s o LOC (AVPU) o If trauma is suspected take initial c-spine precautions o Determine chief complaint if possible o Introduce yourself to bystanders, family members, etc if appropriate, and let them know: Who you are (your name) Your position (I m an EMT or I m an emergency medical technician or a phrase that will denote your competence, credibility and authority.) Why you are with the patient ( I m here to help, and/or, someone called us today, etc.) Did you see (the patient) lose consciousness? And person, place, time and purpose or event if possible. o Unconscious patient intro example: My name is, I m an EMT-medic and I m here to help. Did anyone see what happened? Does anyone know this person? Are you a family member? Do you know anything about this person s medical history? OK. Please tell me what you know so we can help. o Update General Impression ( Big sick/little sick. ) o Prepare for transport (Criteria for immediate transport ( load and go ) are unconscious patient, uncontrolled bleeding, complications of childbirth and severe spinal injuries.) o Start SAMPLE, physical exam and look for medical alert bracelets or medallions o Treat patient as indicated during interview/assessment process SRT Actions The lead EMT is the primary authority and will be responsible for patient contact, obtaining information from the patient, and for directing the SRT. Typical assignments taken by SRT members and usually not by the lead EMT will include: Vital signs Documentation - Fill in the Transfer of Care worksheet by recording pertinent information in all data fields including time of action for 02 administration, all vital signs, etc. Documenter will also prepare the Refusal of Service information sheet (AMA) but the lead EMT will present it to the patient. Airway management Prepare 02 administration as directed by the lead EMT. Trauma management Prepare c-spine precautions, back boarding and strapping as directed by the lead EMT. Communications Interface with incoming ALS personnel and/or other contacts as needed. (Dispatch, hospital, law enforcement, fire personnel, etc.) 32

36 Patient Report When relieved by a higher medical authority or when transferring care, the lead EMT will give a full report on the patient to include: patient s age gender what happened and chief complaint actions taken by the SRT SAMPLE information as necessary. Report Examples #1 (Medical patient) We were presented with a 59 year old female who s chief complaint is dizziness, and who said she was, feeling faint. Patient has a history of low blood pressure and is currently seeing a doctor for it. She wasn t doing anything unusual when the episode occurred. Patient states that she has no allergies that she is aware of. We took a full set of vitals and her blood pressure was 110/60 at We administered high flow 02 through a nonrebreather mask at 15 liters per minute. We gathered the patient s medications and put them in this Ziploc baggie for you. Patient ate a normal breakfast and is not feeling nauseous. She agrees that it would be best for her to be transported to the hospital and be seen by a doctor. Full documentation is on the transfer of care worksheet. We re ready to help you load the patient for transport. #2 (Trauma patient) We arrived on scene of a single vehicle accident; a car hit this telephone pole head on. We have one patient, the driver. There was no airbag deployment and he wasn t wearing a seat belt. He s unconscious and breathing, and has traumatic injuries to the head from hitting the windshield, and the chest from impacting the steering wheel. We ve taken full c- spine precautions. Patient is immobilized on a back board and packaged for immediate transport. Patients pulse is weak and thready at 140 beats per minute. Breathing is shallow and rapid. We are assisting with respirations through a BVM on high flow 02 at 15 liters per minute. Full documentation is on the transfer of care worksheet. We re ready to help you load the patient for transport. 33

37 34 Neurological Exam C-spine Precautions Indicate that this would be done now if not done earlier (as needed). Assess Level of Consciousness (LOC) using AVPU Is the patient alert? (A) Is the patient oriented? (O) Ask the patient: What is your name? (A&Ox1), Where are you? (A&Ox2), What time or day is it? (A&Ox3), What happened to you? (A&Ox4) If not alert, is the patient responsive to: Verbal stimuli? (V), Painful stimuli? (P), Unresponsive? (U) Assess Pupils using PERL Check for size. Check for equality. Check for roundness and regularity. Check for reactivity to light. Assess Extremity Perfusion, Motor Function and Sensation (PMS) Assess upper extremities for distal pulses (presence and equality), movement (presence and equality of grip) as well as sensation in fingers, and capillary refill. Assess lower extremities for distal pulses (presence and equality), movement (presence and equality of strength) as well as sensation in toes, and capillary refill. Describe Findings Verbally Level of consciousness Pupils Distal PMS Objective: The examinee will demonstrate the ability to properly conduct a neurological exam and verbalize the results to the proctor. Equipment: Penlight, patient.

38 35 Bleeding Control and Shock Management Apply Direct Pressure Apply direct pressure to the wound with 4x4s. In cases of profuse bleeding, do not waste time finding a dressing use your gloved hand to apply direct pressure immediately. Apply 4x4s when you can. Expose injury site. Elevate extremity Do not remove a dressing Elevate the injury to above the level of the heart. once it has been applied. If the wound continues to bleed, apply additional dressings over the first one. Pressure Point If a wound continues to bleed, apply firm, direct pressure to the brachial artery. Pressure Dressing Apply pressure bandage over the dressing. The patient is showing signs of shock. What should you do? Position patient supine with feet elevated. Apply high flow oxygen. Cover patient with blanket to prevent heat loss. Prepare for immediate transport. Reassess Check for presence of radial pulse. Note skin signs of patient. Check capillary refill time. Assess distal circulation to ensure bandage was not applied too tight. Objective: The examinee will demonstrate proficiency in controlling bleeding. Equipment: 4x4s, cling wrap.

39 36 Joint Immobilization Prepare the Patient Explain the splinting procedure to the patient. Assess distal pulse, motor function and sensation (PMS) prior to immobilization. Expose affected area. Direct second rescuer to apply manual stabilization of the bones adjacent to the injured joint. Immobilize the Joint Select appropriate splinting material. Position splint in place under the injured joint. Pad as necessary. Secure splint in place with cravats, cling wrap, or other fasteners. Be sure to support the bone ends while positioning the splint. Reassess Reassesses distal pulse, motor function and sensation (PMS). Objective: The examinee will demonstrate how to properly immobilize an injured joint. Equipment: Splinting material, cravats, cling wrap, fasteners, patient.